Antibiotic Allergies in Medical Record: Drug Selection and Validity Effects
Antibiotic Allergies in Medical Record: Drug Selection and Validity Effects
Study Objectives: To determine the frequency with which reported antibiotic allergies alter drug selection and to assess the validity of these allergies.
Design: Retrospective medical record review, with concurrent interviews conducted in a selected subgroup of patients.
Setting: Tertiary care academic medical center.
Patients: Three hundred patients with at least one documented antibiotic allergy and who received an antibiotic while hospitalized.
Measurements and Main Results: Data were collected to determine the patients' allergies documented in the medical record. The first antibiotic regimen that each patient received while hospitalized was evaluated for deviation from the standard of care as determined from institutional protocols, recommendations in the literature, and expert opinion. A total of 416 allergies to antibiotics were reported. Penicillins were the agents most commonly reported (198 reports), followed by sulfonamides, cephalosporins, macrolides, and fluoroquinolones. The reported allergies altered antibiotic therapy in 91 (30.3%) patients. Report of a penicillin or cephalosporin allergy and use of antibiotics for prophylaxis were strong predictors of altered therapy. The subgroup consisted of 100 patients who were interviewed to determine the specific details of their reported allergic reactions. For 22 of the 100 patients, major discrepancies were found between their verbal reports and medical record documentation. The Naranjo adverse drug reaction probability scale was used to determine the validity of their reactions. Among these 100 patients, 109 (78.4%) of 139 reported reactions to antibiotics were deemed to be allergic in nature. For 55 (50.5%) of the 109 allergic reactions, the Naranjo score was 5 or greater, which correlates with probable to definite validity.
Conclusion: Discrepancies between the medical record and in-depth allergy histories are common, and the validity of reported allergic reactions is frequently questionable. Because documentation of an antibiotic allergy frequently alters therapy, increased effort to verify these reactions may be beneficial.
As many as 25% of patients self-report having an allergy to an antibiotic, with 13.8–15.6% reporting an allergy to â-lactams. Estimates of actual allergic reaction rates tend to be much lower than this, calling into question the accuracy of patient reporting. This potential discrepancy poses a problem when antibiotics are being chosen for prophylaxis or treatment of infections. Patients may receive an antibiotic that is not the standard of care. Moreover, allergies to antibiotics may lead to the use of expensive and relatively ineffective agents.
Hospitalized patients requiring antibiotics may present with extraordinary histories of allergic reactions. Researchers at Northwestern Memorial Hospital in Chicago found that 470 (24.8%) of 1893 patients who required antimicrobial therapy reported having a previous allergic reaction to an antibacterial, with 85 (18.1%) of those reporting allergies to several antibacterials. For 295 (15.6%) of all patients, a history of an allergic reaction to penicillin was reported. After penicillin, the agents most commonly reported were sulfonamides, erythromycin, and cephalosporins. In addition, vancomycin and levofloxacin were most frequently used in patients with documented allergic reactions to antimicrobials. With regard to documentation of allergies to antimicrobials, 68% of reports lacked information about the nature and severity of the reaction. Among patients reporting an allergy to penicillins and/or cephalosporins, 39.7% received vancomycin compared with 17.4% who had no reported allergies to antimicrobials. A similar pattern was noted for fluoroquinolones, as 21.5% of patients with reported allergies to penicillin and/or cephalosporins received levofloxacin compared with 8.0% of patients without reported allergies to antimicrobials. The authors concluded that the allergy histories led to prescribing alternative antimicrobials that could have adversely affected both the patient and the institutional resistance pattern.
A retrospective review of medical records at the Tel Aviv Souraski Medical Center, a tertiary-level teaching hospital in Israel, was conducted between January 1997 and December 1998. The cost of antibacterial therapy increased 63% for inpatients and 38% for patients discharged with penicillin allergies compared with nonallergic patients. Therefore, inaccurate or nonspecific documentation of allergies to antibacterials may substantially increase the cost of the antimicrobials prescribed. These findings suggest that antibiotic allergy influences the selection of agents and leads to the use of expensive agents.
Therefore, the primary objective of this study was to determine the frequency with which reported allergies to antibiotics altered drug selection. The secondary objective was to determine the validity of these reported allergies.
Abstract and Introduction
Abstract
Study Objectives: To determine the frequency with which reported antibiotic allergies alter drug selection and to assess the validity of these allergies.
Design: Retrospective medical record review, with concurrent interviews conducted in a selected subgroup of patients.
Setting: Tertiary care academic medical center.
Patients: Three hundred patients with at least one documented antibiotic allergy and who received an antibiotic while hospitalized.
Measurements and Main Results: Data were collected to determine the patients' allergies documented in the medical record. The first antibiotic regimen that each patient received while hospitalized was evaluated for deviation from the standard of care as determined from institutional protocols, recommendations in the literature, and expert opinion. A total of 416 allergies to antibiotics were reported. Penicillins were the agents most commonly reported (198 reports), followed by sulfonamides, cephalosporins, macrolides, and fluoroquinolones. The reported allergies altered antibiotic therapy in 91 (30.3%) patients. Report of a penicillin or cephalosporin allergy and use of antibiotics for prophylaxis were strong predictors of altered therapy. The subgroup consisted of 100 patients who were interviewed to determine the specific details of their reported allergic reactions. For 22 of the 100 patients, major discrepancies were found between their verbal reports and medical record documentation. The Naranjo adverse drug reaction probability scale was used to determine the validity of their reactions. Among these 100 patients, 109 (78.4%) of 139 reported reactions to antibiotics were deemed to be allergic in nature. For 55 (50.5%) of the 109 allergic reactions, the Naranjo score was 5 or greater, which correlates with probable to definite validity.
Conclusion: Discrepancies between the medical record and in-depth allergy histories are common, and the validity of reported allergic reactions is frequently questionable. Because documentation of an antibiotic allergy frequently alters therapy, increased effort to verify these reactions may be beneficial.
Introduction
As many as 25% of patients self-report having an allergy to an antibiotic, with 13.8–15.6% reporting an allergy to â-lactams. Estimates of actual allergic reaction rates tend to be much lower than this, calling into question the accuracy of patient reporting. This potential discrepancy poses a problem when antibiotics are being chosen for prophylaxis or treatment of infections. Patients may receive an antibiotic that is not the standard of care. Moreover, allergies to antibiotics may lead to the use of expensive and relatively ineffective agents.
Hospitalized patients requiring antibiotics may present with extraordinary histories of allergic reactions. Researchers at Northwestern Memorial Hospital in Chicago found that 470 (24.8%) of 1893 patients who required antimicrobial therapy reported having a previous allergic reaction to an antibacterial, with 85 (18.1%) of those reporting allergies to several antibacterials. For 295 (15.6%) of all patients, a history of an allergic reaction to penicillin was reported. After penicillin, the agents most commonly reported were sulfonamides, erythromycin, and cephalosporins. In addition, vancomycin and levofloxacin were most frequently used in patients with documented allergic reactions to antimicrobials. With regard to documentation of allergies to antimicrobials, 68% of reports lacked information about the nature and severity of the reaction. Among patients reporting an allergy to penicillins and/or cephalosporins, 39.7% received vancomycin compared with 17.4% who had no reported allergies to antimicrobials. A similar pattern was noted for fluoroquinolones, as 21.5% of patients with reported allergies to penicillin and/or cephalosporins received levofloxacin compared with 8.0% of patients without reported allergies to antimicrobials. The authors concluded that the allergy histories led to prescribing alternative antimicrobials that could have adversely affected both the patient and the institutional resistance pattern.
A retrospective review of medical records at the Tel Aviv Souraski Medical Center, a tertiary-level teaching hospital in Israel, was conducted between January 1997 and December 1998. The cost of antibacterial therapy increased 63% for inpatients and 38% for patients discharged with penicillin allergies compared with nonallergic patients. Therefore, inaccurate or nonspecific documentation of allergies to antibacterials may substantially increase the cost of the antimicrobials prescribed. These findings suggest that antibiotic allergy influences the selection of agents and leads to the use of expensive agents.
Therefore, the primary objective of this study was to determine the frequency with which reported allergies to antibiotics altered drug selection. The secondary objective was to determine the validity of these reported allergies.
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